Dental and vision plans: What they are and how they work

This article will help you understand: 

• Why dental and vision coverage are important for your health?
• How dental plans work
• How vision plans work
• Where to get vision and dental insurance
• FAQs

 

Why it’s important to have vision and dental insurance.

The fact is, oral and eye health are essential to our overall wellbeing. Many serious conditions can be detected in their early stages by an eye exam, including diabetes, high cholesterol, and hypertension.¹ Oral exams can be just as revealing: More than 90% of all common diseases have oral symptoms.² And the importance of oral health goes beyond detection: Guardian studies – and other third-party research – show that good oral health can help adults avoid or better manage serious health-related issues:

• Diabetes. Periodontal infections contribute to problems with glycemic control, which compromises the health of diabetic patients.
• Heart disease. The inflammation associated with periodontal disease has a high potential to contribute to coronary artery disease. Good oral health can lower that risk.
• Pregnancy. Studies have indicated that mothers with high levels of certain oral bacteria were found to have children with similarly high levels of bacteria, along with a higher risk of tooth decay.
• Self-esteem. Research shows that healthy teeth and gums are important to a person’s self-esteem and how they feel about themselves.

All this should come as no surprise. It’s hard to consider yourself a healthy and happy person when your eyesight is impaired, your mouth hurts, or you’re worried about what’s happening with your teeth.

What dental insurance is – and how it works.

Dental plans generally fall into one of two categories: basic coverage and full coverage. Generally speaking, a basic dental plan covers preventive care such as checkups, cleanings, x-rays and a few basic procedures, like cavity fillings.

Full coverage plans cover much more – and often at a lower out-of-pocket cost to you. For example, they may cover a wider range of preventive procedures such as fluoride treatments and sealants – and they may cover those treatments in full or with just a small copay. In addition, a good full coverage plan (like the ones offered by Guardian) will cover other types of procedures, including:

• Basic restorative care:  This includes fillings, extractions, and non-routine X-rays
• Major restorative care: Bridges, crowns, dentures and the like
• Orthodontic treatment:  Braces and other types of teeth aligners 

Most plans have a provider network.

Dental provider networks come in two basic varieties: Dental HMOs and Dental PPOs. (There are also “Indemnity” plans that don’t have a network – instead, they reimburse a portion of your dental expenses.) In a DHMO you have to see an in-network dentist – and because their networks are limited, you probably won’t get to see your current dentist; the trade-off is generally lower costs and a simpler fee structure.

A DPPO also has a network of dentists, but typically lets you go out of network to see another dentist. But if you go with a large insurer– with a broad provider network – your current dentist may well be “in-network.” It’s almost always worth your while to see an in-network dentist in a DPPO, because the insurance company negotiates discounted fees on your behalf. So for example, if your dentist typically charges $100 for a filling, when he or she is in-network you may only be charged $60-$70 – even if you haven’t met your deductible yet.

Not all costs are covered – even with a full coverage plan.

The out-of-pocket cost you pay for a given dental treatment may vary widely depending on the insurance company and specific plan you choose. When you’re looking at a plan's details, the following items should be clearly spelled out:

• Premiums. The amount you pay per month for the plan. Look in the FAQ for a chart showing the typical range of dental premium costs.
• Deductible. The amount you have to pay before the plan starts to pay for treatments. DPPO plans tend to have deductibles, but many DHMO plans do not.
• Coinsurance. The percentage of costs you have to pay for a visit or treatment once you’ve met your deductible. With a DHMO, there isn’t a deductible, and you will typically pay a flat fee or copay depending on the services received.
• Annual Maximum. The total amount your plan will pay you in a given year. You have to pay for any treatments over that amount – but remember: if you go in-network you will still be able to take advantage the plan’s discounted fees.

Every plan is different – so look at the details.

In addition to looking at the premiums, deductible, coinsurance, and annual maximum to understand all the costs of the plan, you should also look for such things as:

• Types of services and treatments covered. You may not recognize the names of all the procedures covered—but usually the longer the list, the better.
• Waiting periods.  Major procedures, such as crowns, usually have a waiting period (for example, 12 months) before they are covered.
• Primary dentist requirement.  This is typical of DHMOs but some DPPOs also have this requirement. It means that you have to go through your regular dentist to get a referral to see a specialist.

If you go to Guardian Direct, you’ll see all that information clearly laid out. The example below shows a Guardian Dental Advantage Gold Pro Plan for a family in New York.

	Guardian Pays
Cleanings & X-Rays	100%
Fillings	70%
Root Canals, Crowns	50%
Implants	50%
Child Braces (under 19)	50%

 

Year 1,2,3	$1,000, $1,250, $1,500
Implants Lifetime	$1,000
Child Braces Annual	$500
Child Braces Lifetime	$1000

What vision insurance is – and how it works.

Vision insurance works a little differently than dental insurance. Like a dental plan, a vision plan provides coverage for routine exams not covered by most medical plans, but it also offers discounts on eyeglasses and contacts needed to correct vision problems. However coverage for many serious treatments, such as non-elective surgery to correct an eye injury, typically isn’t covered because it’s part of your major medical plan. So vision insurance also tends to be very affordable (the FAQ shows a typical range of vision plan premiums).

Why get a vision care plan?

Whether you have perfect vision or need corrective lenses, preventive eye care is an important part of your overall health. More than 83% of Americans report using digital devices for more than 2 hours per day, and 60% report digital eye strain. For children, poor eyesight can lead to misdiagnosis of learning and psychiatric disorders which can result in behavioral problems.⁴

75% of us use vision correction – so even if you have 20/20 vision now, chances are you’ll need vision correction at some point in your life. Adults and children alike should have an annual eye exam to test for such things as sharpness of vision, color blindness, how the eyes work together as a unit, the presence of glaucoma, range of peripheral vision, and more. The exam can also provide early detection of serious conditions such as diabetes, glaucoma, and eye disease.

For just a few dollars a month, a vision plan can make annual eye exams far more affordable, while also helping you save on other types of eye care:

Eyewear. Glasses (frames and lenses) and contact lenses can be expensive – but are often at least partially covered by vision insurance. Sometimes, even prescription sunglasses may be covered.

Lens coatings and enhancements. Some vision insurance plans can help with the cost of lens coatings that help decrease scratching, fog and moisture, reflections, and exposure to ultraviolet rays.

Corrective surgery. Surgeries that are deemed medically necessary, such as a procedure to treat an eye disease, will often be covered by a health insurance plan. But corrective surgery, such as LASIK, is generally not covered by health insurance because it is deemed to be an elective or “cosmetic” surgery. However, some vision insurance plans will partially cover these procedures.

Where to get vision and dental insurance.

If you or your spouse have dental and/or vision benefits through work, that’s almost always the way to go. The employer may pay the premium or it may be offered as a voluntary benefit, which means the employee pays the entire premium. (Either way, companies tend to get lower group rates, which means you might pay less than if you purchased the same insurance as an individual.

If that’s not an option, consider buying directly from a dental plan insurance carrier. Guardian has affordable Vision plus a range of Dental DHMO and DPPO plans with a broad provider network. Guardian offers better savings than the industry average, while its strong network provides a number of advantages:

• With over 114,000 dentists in the Guardian DPPO network, it can be easy to find a dentist to fit your needs.
• If you see an in-network dentist, you may save up to 35% off standard dental rates.
• Guardian also offers VSP, as well as Davis Vision.

Whichever insurance company you choose, make sure they provide a few different plan options. And take the time to compare the plans offered, keeping in mind that the plan with the lowest premium may not provide the best value for your family’s needs.

Finally, if you’re a senior on Medicare, take a look at Medicare Advantage plans that offer dental and vision benefits not covered by regular Medicare.

Frequently asked questions about dental and vision insurance.

Should children get vision and dental insurance?

The Affordable Care Act  has minimum essential requirements for pediatric vision and dental care, so these will be covered under your medical plan. But keep in mind ACA pediatric vision coverage doesn’t typically cover corrective lenses and frames, and dental coverage is relatively limited as well. That’s why many parents with young children find it important to have additional dental and vision coverage.

Does Medicare offer vision and dental insurance for Seniors?

Vision and dental benefits are not offered under Medicare Part A and Part B. They are offered by many Medicare Advantage plans, a program not offered by Guardian. Affordable vision and dental insurance for seniors can be purchased directly from Guardian.

Where can you get dental and vision insurance?

The same kinds of dental and vision insurance plans, offered by employers, can be purchased by individuals. A good place to start is at Guardian Direct.

Is corrective surgery covered by vision plans?

Some vision insurance companies and plans will offer discounts or partial coverage for these procedures.